APPLICATION

For
VOLUNTEER SERVICES

PHYSICIANS REGIONAL
HEALTHCARE SYSTEM
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VOLUNTEER SERVICES
"The world is hugged by the faithful arms of volunteers"

Dear Potential Volunteer,

Volunteers have played a critical role in hospitals for centuries. The volunteers at Physicians Regional Healthcare
System graciously donate their time and energy into assisting our patients, visitors and staff. Becoming a
volunteer will enrich your life. Whether you want to have direct contact with patients or work behind the scenes
you will make new friends and make a difference in our community.

In order to qualify for the program and become a member of our team:

• Commit to at least 6 consecutive months from date of orientation (adjusted for seasonal residents) and
work a minimum of four hours, once a week.
• Apply .......... Please fill out application attached and return or mail to your preferred location:

Physicians Regional Healthcare System Physicians Regional Healthcare System

Jane Fleming/Volunteer Coordinator Kim Myers/Volunteer Coordinator
6101 Pine Ridge Rd 8300 Collier Blvd.
Naples, Florida 34119 Naples, Florida 34114

• HealthCare Screening. . Complete an Employee Health Department review (Includes Immunization

Review/Tuberculosis Screening and a Substance Test)

• Background Screening. . All volunteers over 18 are required to have a Background Check.

• Attend Orientation . . . . Although you are not an employee you are required to attend a portion of the
Hospital's New Employee Orientation and Volunteer Orientation.

Once your application is received we will contact you for an interview. If you have any questions or concerns
please contact the applicable office: Pine Ridge 239-348-4087, Collier 239-354-6072

Thank you for your interest in becoming a member of the volunteer team at PRHS!

Sincerely,

Kim and Jane

Your Volunteer Coordinators

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VOLUNTEER SERVICES APPLICATION

LAST NAME: FIRST NAME:

ADDRESS:

CITY: STATE: ZIP: BEST CONTACT PH#:

EMAIL:

Do you speak any foreign languages? No: O Yes: O If "Yes" please list

SEASONAL O FULL TIME O (If seasonal check months available)

JAN FEB MARCH APRIL MAY JUNE JULY AUG SEPT OCT

NOV DEC

PREFERRED ASSIGNMENT LOCATION: 6101 Pine Ridge Rd O 8300 Collier Blvd O

EMERGENCY INFROMATION:

Emergency Contact Name:_____________________________________________________

Relationship to you:_________________________ Home Phone: ______________________

Work Phone: ______________________________ Cell Phone: ________________________

QUESTIONNAIRE:

Why are you interested in volunteering?

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Are you currently seeking volunteer experience to fulfill a community service obligation? (i.e church, school)
No: O Yes: O - If yes, briefly describe the service requirements:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Service Organization & Contact: __________________________________________________________
Phone Number: __________________________________
How many volunteer hours do you require for school? _________________________

QUESTIONNAIRE cont'd
1) Is there anything that may adversely affect your ability to perform volunteer work?

No: O Yes: O If yes, please describe in detail: ____________________________________

2) Are there any accommodations needed in order for you to safely and competently perform

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Volunteer work as requested? _______________________________________________________

_______________________________________________________________________________

3) Do you have any physical, visual or hearing needs we need to consider?

No: O Yes: O If yes, please explain: ___________________________________________

____________________________________________________________________________

4) Are you physically able to transport patients in a wheelchair? Yes: O No: O

PLEASE REVIEW VOLUNTEER ASSIGNMENT DESCRIPTION EXAMPLES (attached):

WORK PREFERENCES (Please check all that apply):

Patient Contact: O Non-Patient Contact: O Informational / Clerical: O

CIRCLE AREAS OF INTEREST ..... IF NOT LISTED WRITE BELOW

Book/Serving Cart Employee Health Emergency Room

Employee Health Food and Nutrition Golf Cart Driver

Hospital Attendant Human Resources Infection Control

Information Desk Lab & Radiology Marketing

Materials Delivery Medical Records Pharmacy

Radiology/Mammography Rehabilitation Services Risk Management

Surgery Center-PACU Volunteer Office Volunteer Ambassador

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

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PLEASE CIRCLE THE DAYS AND HOURS YOU WOULD BE AVAILABLE:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

6-10am 6-10am 6-10am 6-10am 6-10am 6-10am 6-10am

8am-12pm 8am-12pm 8am-12pm 8am-12pm 8am-12pm 8am-12pm 8am-12pm

12-4pm 12-4pm 12-4pm 12-4pm 12-4pm 12-4pm 12-4pm

4-8pm 4-8pm 4-8pm 4-8pm 4-8pm 4-8pm 4-8pm

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EDUCATION AND EMPLOYMENT HISTORY (Please check all that apply):

Actively Working: O Retired: O Student: O

Are you 18 years or older? Yes: O No: O

EDUCATION:
High School Graduate: Yes: O No: O College Degree: Yes: O No: O If yes, List
Degree/Major: _____________________________________________________________________

EMPLOYMENT EXPERIENCE:

Have you ever worked at a hospital? Yes: O No: O

Last Place of Work - if any:

Business Name:________________________________________________________________________

Address:_______________________________________________ Phone: __________________________

Position:_______________________________________________ Supervisor's Name:_________________

Do you hold any special medical or clinical certifications or licenses, or had medical training of any type?

Yes: O No: O If yes, Please List:________________________________________________________

____________________________________________________________________________________

VOLUNTEER EXPERIENCE:

Name of Organization:_________________________________ Supervisor's Name:__________________

Supervisor's Phone:_____________________________________ OK to Contact: Yes O No O

Duties Performed: __________________________________________________________________

PLEASE LIST ANY SPECIAL SKILLS OR CERTIFICATIONS (ie: Previous employment positions or training,
hobbies or interests, healthcare experience, patient care services etc. Complete on back if required):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

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REFERENCES:

Please complete references below and include any Letters of Reference for any current or former job supervisors,
teachers or clergy. Family members, relatives and friends may not provide recommendations.

Reference 1 Name: Phone:

Relationship to you: Business Name:

Address: City: State: Zip:

Reference 2 Name: Phone:

Relationship to you: Business Name:

Address: City: State: Zip:

How did you hear about our volunteer program?_________________________________________________

Have you ever been convicted of a felony? Yes: O No: O

Have you ever been convicted of a misdemeanor? Yes: O No: O

If yes, please explain details including dates: __________________________

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________________________________________

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CERTIFICATION AND AUTHORIZATION:

I certify that the information I have provided is true and complete to the best off my knowledge. I
understand that misrepresentation, falsification, or omission of information may disqualify me from
further consideration for volunteering, or may result in my termination as a volunteer.

If accepted as a volunteer, I understand that I must abide by all of the policies, rules and regulations of
the Physicians Regional Healthcare System.

I authorize Physicians Regional Healthcare System to investigate all statements contained in this
application and to make inquiries of my personal references and medical history, as well as other
related matters as may be necessary for determining my eligibility as a volunteer. I hereby release
physicians, employers, schools or individuals from all liability in responding to inquiries relating to my
volunteer application.

Signature:_____________________________________
Printed Name: _________________________________ Date:________________

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VOLUNTEER ASSIGNMENTS DESCRIPTION

Too often we underestimate the power of touch, a smile, a kind word, a

listening ear, an honest complaint, or the smallest act of caring, all of
which have the potential to lighten the burdens of others.

The volunteer's at Physicians Regional Hospital System help lighten the burden of our patients, staff and visitors
every day. They are very compassionate and caring individuals. The fact you are considering devoting your time
and effort is the first step in becoming a valuable member of our team.

VOLUNTEER ROLE

People choose to volunteer for many reasons. It could be that they want to meet new friends, gain exposure to a
future career, stay busy after retirement, obtain a sense of gratification or satisfaction, have a need to help or to
offer their professional skills, want to make an impact in their community, or simply have fun.

Placement Overview:

Volunteering should provide a source of pride and enjoyment. Capturing your areas of interest before placement is
important to us and we will try to do so through your volunteer application and your interview with the Director of
Volunteer Services. You are not locked into any one department. Once you are accepted as a volunteer and would
like to change your assignment just contact the Director of Volunteer Services and every effort will be made to
accommodate you.

Volunteer Placement Description:

To assist staff throughout the hospital, adding a personal touch to help provide comfort to patients and family
members, as well as provide service and support to hospital staff. Your Director of Volunteer Services will provide
you with a volunteer placement description (competency-based), as well as training, for the department(s) where
you will volunteer.

Volunteers should never be used to replace an employee, nor should they ever provide any medical
services to patients. Volunteers are utilized to assist patients and staff members throughout the hospital.
They should only perform services that constitute "extras" designed to help patients and their families.

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GENERAL VOLUNTEER DUTIES

Miscellaneous Volunteer Duties: Definite " NO ” for Volunteers:

Duties vary by department, however key duties
This list can be large, but here are a few identified
often include:
tasks that volunteers cannot do:
• Answering phones, light filing and general office
duties • Bathe patients
• Assist with hospital tours and special events
• Deliveries to patients (i.e. magazines, menus, • Clean dentures
books, newspapers, flowers) • Feed patients
• Errands for units
• Foreign language translation • Handle soiled linens
• Patient escort and/or transportation within hospital • Transport soiled instruments
(with training)
• Patient floors: provide comfort, get water, etc. for • Transfer patients from bed to chair and vice versa
patients; assist staff with errands • Transfer patient via wheelchair if patient is on IV
• Restock supplies where needed
• Sign language • Remove bedpans/urinals
• Greet, assist and comfort patients, family and • Transport narcotics
visitors
• Assist with newsletters or mailings • Read patient's chart
• Assist with special projects
• Restock carts for patient floors

ASSIGNMENT DESCRIPTIONS - EXAMPLES

Nearly every hospital department has opportunities for volunteers.

ASSIGNMENTS INVOLVING PATIENT CONTACT

Hospital Attendant: Refill Water Pitcher, Empty trash and pick up around room if needed, answer call
light for non-clinical needs, bring extra pillows, comfort patient with warm blankets, help visitors get
acquainted and answer questions, spend time with patient, assist staff with any filing or paperwork.

Same Day Surgery Recovery: Assisting staff when patients come out of surgery. Getting patients
something to drink, warm blanket, restocking supplies, room turnover, assisting with discharging patients
by wheelchair (wheelchair training will be required).

Emergency Department: Greet and escort patients and visitors and assist them in getting registered at
Triage desk, keeping track of families in waiting room or work in the treatment area assisting staff with
room turnover and restocking supplies.

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ASSIGNMENTS INVOLVING NON PATIENT CONTACT

Customer Service: (available at different departments and desks in the hospital) Greeting and checking
in families. Escorting patient and visitors, keeping track of families in waiting room, offer wheelchair
service (wheelchair training will be required).

Customer Service Greeter / Escort: Greet patients and visitors at entrance. Open car doors, call for
Golf cart service, escort patient and visitors, offer wheelchair service (wheelchair training will be
required).

Food and Nutrition: Assist in cafeteria, cleaning tables wiping trays, restocking.

Golf Cart Driver: The responsible driver will have a valid Florida Drivers License, friendly individual to
greet patients and visitors, assist with transport to and from the hospital entrance, direct patients and
visitors to hospital entrances, report any issues in the parking area to security.

Courier: Transporting items to various locations throughout the hospital and assisting with discharging
patients.

ASSIGNMENTS INVOLVING INFORMATIONAL /CLERICAL

Lobby Information Desks: Greet and escort patient and visitors, computer work, answer
phones, look-up patient information for visitors.

Clerical Support: Assist in various departments with answering phones, greeting customers, filing,
making copies and sorting paperwork.

Radiology: Pulling and filing x-ray jackets. File reports into patient charts, duplicating films in darkroom,
assisting clerical staff with patient requests.

VOLUNTEER AMBASSADOR:

In addition we are recruiting individuals to join our Volunteer Ambassador Program. Volunteer
Ambassadors are specifically trained to spend time with our patients, families and their visitors. They
provide a very special service to Physicians Regional Healthcare System. . . . Volunteers who have the
time to spend as an Ambassador will provide comfort, emotional support and a friendly smile when it
really counts.

For those who volunteer in a specific department on a regular basis you will be provided with a
Department Specific Assignment Description and the Department Manager or other designated
employee of that department will conduct an initial training session. Know that your dedication can
make a difference in people's lives, no matter where you serve. Each assignment has something that will
make you feel positively proud.

RETURN YOUR APPLICATION TODAY WE WILL GET YOU

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